Trimet Safety Final Report

8/8/2019 Trimet Safety Final Report

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Final Report

TriMet Safety & Service Excellence Task Force

10/20/2010


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SSETF Final Report Page 2

TASK FORCE ON SAFETY & SERVICE EXCELLENCE

October 19, 2010

Mr. Neil McFarlane, General Manager

TriMet

4012 SE 17th

Ave

Portland, OR 97202

Re: Final Report

Dear Neil:

Enclosed please find the final report from the task force you appointed shortly after becoming

general manager in July of this year.

The tragedy of April 24, 2010, drove the direction and intensity of the task forces work. This

fateful occasion was clearly the darkest night in TriMets history. The focus of our

recommendations is to help you migrate TriMet to the highest level of safety performance, so

that such an event never happens again.

Your staff, K&J Consultants, members of the public and TriMet employees contributed greatly

in shaping our views. Ultimately, the attitudes, ethics and input of your operators are the mostimportant. Together with your leadership, these dedicated individuals will be instrumental in

elevating safety as a cultural value at TriMet.

Please accept our appreciation for the opportunity to serve you with these recommendations,

and our willingness to provide further assistance.

Sincerely,

Tom Walsh

Chair, Task Force on Safety & Service Excellence


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Table of Contents

Page

1. Introduction .........4i. Charge . ..4ii. Process . .4iii. Direction ......4iv. Purpose . 5v. Problem Statement ...5vi. Principal Recommendations . .5

2. Detailed Recommendations and Observations . .6i. TriMet Culture . ....6ii. Communications and Engagement . ..6iii. Accountability, Empowerment and Support . .7iv. Tools, Systems and Processes . ..9

3. Concluding Remarks.104. Appendices and Attachments . .11

i. Appendix A: Task Force Members ..12ii. Appendix B: Summary of Meetings 14iii. K&J Phase I: System Safety Review and Evaluation of Policies,

Procedures and Training (Attachment)

iv. K&J Phase II: System Safety OnSite Assessment (Attachment)


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Introduction

TriMets most serious collision in its history occurred on April 24, 2010, when a bus hit five

people in a crosswalk, killing two and seriously injuring another. The agency immediately

launched a toptobottom safety review with the assistance of an expert affiliated with the

National Safety Council, as well as a linebyline assessment of every bus route to improvesafety.

Shortly after the launch of this initiative, Neil McFarlane took over as TriMets general manager,

making safety and service excellence the focus of his first months in office. His first step was to

create a 12person Task Force on Safety and Service Excellence. Members of the task force

included stakeholders with key areas of expertise such as public safety, traffic engineering,

professional drivers, pedestrians, bicyclists, private business and TriMet bus and rail operators.

ChargeMr. McFarlane suggested that organizations with the highest level of safety performance are

also organizations that deliver excellent customer service. His charge to the task force:

How to migrate TriMet to the highest levels of safety performance, and thereby improve

performance in all areas of its business.

Process

The task force built upon the work ofTriMets toptobottom safety review, including a review

of the technical safety reports provided by K&J Safety and Security Consulting Services, Inc. It

examined many facets of the agencys organizational culture and structure, including how

TriMet sets and communicates priorities and how decisions are made that affect safety

outcomes.

The task force reported directly to the general manager, and held nine meetings between July

29, 2010, and October 20, 2010, including four sessions open to the public and five work

sessions. All public sessions included time for public comments from stakeholders, employees

and outside experts.

Direction

TriMet can migrate to the highest levels of safety performance, and thereby improve

performance in all areas of its business by creating a culture where safety is not just a priority

it is a value.


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TriMets success in this migration will depend on the general manager taking ownership and

acting as the driving force. Commitment from the board of directors will also be key. The

recommendations in this report are provided to the general manager to help implement this

cultural shift. To achieve success, TriMet will have to build upon the observations and

recommendations of the task force, and implement them in a way that is sustainable over time.

Many of the recommendations presented by the task force are by necessity general in nature.

Its mission was not to produce detailed action plans; rather, directional guidance that TriMet

can utilize to ensure the safety of people in and around TriMet. Some recommendations might

lead to relatively quick adjustments in programs and activities, while others are more structural

requiring greater time for implementation.

The task force will be available to reconvene to evaluate and comment on TriMets progress, if

it would be of value to the general manager.

Purpose

The purpose of this report is to provide the general manager with guidance for further action.

What follow are recommendations in four major areas that are intended to help TriM ets

general manager improve the safety performance of the organization.

Problem Statement

Testimony from employees, management staff, the public and K&J Consulting helped the task

force to develop the following problem statement:

Safety at TriMet is one of a number of priorities that compete for limited time, attention and

resources. TriMets commitment to safety and service excellence across its many divisions

and vertically through its ranks is uneven.

Principal Recommendations

To help TriMet create a culture that structurally and practically places safety at the forefront,

the task force arrived at four principal recommendations:

1. TriMet Culture: Make safety a value, not just a priority, by transforming TriMets culture.2. Communication and Engagement: Empower operators to be active participants in their

work as the face of the agency to the public. Engage the community in helping TriMet be

successful in an evergrowing complex operating environment.


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3. Accountability, Empowerment and Support: Elevate and expand the Safety Department byappointing an Executive Director of Safety, who will be responsible for developing and

implementing a comprehensive safety program, enhanced tools for accountability, and an

employee support structure.

4. Tools, Systems and Processes: Develop metrics for driving performance and make betteruse of safety data to inform decision making.

Detailed Recommendations and Observations

TriMet Culture

Safety needs to be an organizational valueevident in all aspects of the agencys worknot

just a priority subject to competition for resources, time and attention.

1. General managers call to actionThe general manager should clearly articulate safety as an organizational value to the

board, the public and TriMet employees, and provide leadership that models the shift in

elevating safety to the fundamental value of the organization.

In doing so, every decision should be viewed through a safety lens. This includes

development and implementation of policies and procedures, scheduling of routes,

allocation of resources in TriMets annual budget and more.

Communications and Engagement

2. Employee engagementMore opportunities are needed for employees to engage leadership in frank discussions

about safety. TriMet should consider holding meetings on a regular basis where employees

are able to provide feedback to managers and leadership. Topics should reach beyond

specific issues of safety to include service excellence and TriMet culture.

3. Strategic data sharingTriMet should make safety performance data readily available and visible in employee

common areas to help draw broader attention to safety performance and to driveawareness of it as a critical measure.

4. Community advisory committeeTriMet cannot achieve the highest levels of safety performance without engaging the entire

community. The task force heard from operators that the rules of the road and the physical

environment in which they operate dont always accommodate a conflictfree environment.


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Members of the public have described their need for more collaboration between TriMet

and its customers and partners both in decisionmaking processes and in response to

identified issues.

Community conversations will be required to harness the knowledge of all constituents and

thereby improve the safety ofthe regions public transportation for everyone. TriMet

should consider a community advisory committee that would allow TriMets customers and

partner stakeholders the opportunity to weigh in as TriMet makes decisions. It would also

provide an opportunity for customer engagement on the agency level beyond the

limitations of current public testimony to the board. Engagement with the community

should also include an improved process for collecting and responding to safety issues that

are identified by the public.

5. Engagement with partner organizationsTriMet should continue to strengthen its work with partner organizations in theidentification of hazards. Metros new transportation safety committee may be a resource

for TriMet.

6. Language and definitionsWithin TriMet there is no common definition of safety or universal understanding of what it

means. There is limited ownership of safety in the language TriMet uses, e.g., the frequent

use of accident when referring to collisions and the perceived comfort with non

preventable as a description.

TriMet should eliminate the term accident from its vocabulary to the extent practicable,

and instead use words that are descriptive of the event in order to highlight the predictable

and preventable nature of most collisions and injuries.

Additionally, TriMet should shift emphasis to the concepts and terminology around hazard

identification from accidents, which underlines a more proactive approach to safety.

Accountability, Empowerment and Support

7. Executive Director of SafetyThe Phase I K&J Report identified the need for a director of safety who reports directly to

the general manager. The task force believes this position should be elevated to the level of

executive director to ensure that the person selected is engaged in leadership conversations

and decision making at the executive leadership team level.


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This individual would be responsible for breaking down silos and uniting all aspects of

operations to support a comprehensive safety program. His or her work would include the

oversight and implementation of many of the recommendations in this section.

8. Hiring and training practicesThe hiring process should be evaluated to ensure that safety is instilled as a value from the

moment a person becomes an employee of TriMet. TriMet should evaluate and identify

desirable qualifications in recruiting new employees, based on safety performance and

service excellence.

TriMet needs to emphasize safety in its ongoing training efforts. The relationship of the

Safety Department and the Training Department should be examined and consideration

should be given as to what organizational structure maximizes the relationship between the

two departments.

The task force heard that all newly hired bus operators enter the agency as parttime

operators. This may limit the talent pool and could present other challenges. This issue

should be examined.

TriMet should also look at ways to nurture mentorship opportunities between senior and

new operators.

9. Health and wellnessTriMet should focus on programs that create an environment where employees can be

healthy, welltrained, successful people. Addressing health and wellness, advancing training

goals and providing professional development opportunities will foster a supportive and

healthy environment for TriMets employees, better equipping them to provide a safe and

rewarding transit experience to TriMet customers.

10.Recognition programsTriMet should evaluate existing recognition and incentive programs and align them with

safety as an organizational value. These programs should be constructed in a way that

rewards achievement in safety and service excellence, and motivates employees to improve

their performance.

11.Union engagementTriMet should use its best efforts to garner the support of ATU leadership, as

representatives of TriMets frontline employees, in instilling safety as a value at TriMet.


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Tools, Systems and Processes

12.Safety DashboardSafety must be measured from a known baseline to improve performance. Currently,

TriMet does not sufficiently mine or analyze data to support the identification of hazards

and to proactively work towards incident prevention.

TriMet should develop a safety dashboard, comprised of key metrics that can be used to

continually monitor and report on safety performance.

13.Data analysis in support of hazard identification and incident preventionTriMet should use inhouse resources to evaluate safetyrelated data. Data that are

collected should be analyzed and distilled into information that can readily inform operator

training, service planning, line risk assessments and response to operator feedback.

The new Executive Director of Safety should be responsible for ensuring that the safety

program includes a comprehensive framework and methodology to identify risks and

hazards, and minimize or eliminate those hazards to prevent incidents. This would include

making sure that all operator feedback, incident reports, customer comments and

supervisor observations must be communicated in a way to support the safety agenda.

14.Yellow Card programThe Yellow Card program (operator feedback) and the Service Improvement Process

(customer feedback) should be reviewed to ensure that safety issues are addressed in a

timely manner and that operators are notified of the evaluation/action taken. Further,TriMet should consider wholly rebranding the Yellow Card program to ensure that any

improvements are not overshadowed by baggage that may come with its previous title.

15.Systematic hot spot reviewTriMet should use data to determine where safety hot spots may exist or are likely to

develop over time, and take a systematic approach to evaluating and treating such hot

spots. Based on employee comments to the Task Force, the Portland Transit Mall is a hot

spot in need of review.

Such a review would require working with partner organizations to address the relationship

between three spheres of influence over safety on the street: (1) the operator and bus

equipment; (2) the roadway, track way and related infrastructure; and (3) other users, such

as cyclists, pedestrians and motorists.


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TriMets recent evaluation of its bus and MAX lines that was part of its toptobottom safety

review is an example of such review and partnership, and TriMet should develop this

concept into an ongoing process.

16.Employee safety committeesThe new Executive Director of Safety should elevate the importance of employee safety

committees. This would improve employees sense of ownership in the working

environment, tapping those who are closest to the work and in the field the most for

valuable information.

Presently, the members of the safety committees are frustrated with their inability to affect

change, and the structure of the committees suggests that they have been marginalized

over time.

17.Scheduling and safetyThe task force heard frustrations from some employees about bus operating schedules.

Based on this testimony, there may be a tension between the pressure to achieve ontime

performance and safety. While maintaining schedules is certainly a priority for TriMet, it

should never be at the expense of safety. Follow up work may be necessary to ensure that

the process of developing schedules involves input from the safety and training

departments and operator feedback.

18.CCTV use with operatorsNumerous properties have installed CCTV cameras that show the operators compartment,

and video has been used to enhance safety and customer service. We concluded that the

role of CCTV should be further evaluated by TriMet for the purpose of enhancing safety,

training and customer service.

19.Improved emergency plansTriMet should look at emergency plans to improve support structures and communications

for employees and riders during emergency situations, including severe weather.

Concluding remarks

The task force thanks the many employees who spoke candidly about their concerns and

offered their suggestions, the staff who provided information, and the public who gave

testimony both passionate and constructive. We are hopeful that this report will form the

foundation for ushering in a culture where everyone at TriMet is a steward of safety.


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List of Appendices/Attachments

A. Task force member rosterB. Summary of Issues CoveredC. K&J Phase I: System Safety Review and Evaluation of Policies, Procedures and Training

(Attachment)D. K&J Phase II: System Safety Onsite Assessment (Attachment)


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APPENDIX A.

Safety & Service Excellence Task Force Members

Robert Burchfield

Robert is the city traffic engineer for the City of Portland, and manages Portland's Traffic

Operations Division, including traffic investigations, parking control and data collection.

Greg Butler

Greg has been with TriMet for 13 years, first as a bus operator and as a MAX operator since

2003. He operates the extra board, meaning that he works on all lines across the service day,

with a great deal of experience on the system. He was voted Rail Operator of the Quarter by his

peers during 2009, safe operation is an important component of receiving this recognition.

Jan Campbell

Jan works for Multnomah County Aging and Disability Services, and is the chair of TriMet's

Committee on Accessible Transportation, a citizen advisory committee to the TriMet Board of

Directors that represents seniors persons with disabilities. Jan is also Vicechair of Disability

Rights Oregon, Commissioner on the City and State Disability Commissions, CoChair of Women

with Disabilities Health Equity Coalition, a member of the NW Regional ADA Steering

Committee, and a member of the Connecting Communities Coalition.

Shirley Carter

Shirley has been a TriMet bus operator for almost 18 years, and looks forward to retiring in thefall. Shirley is a favorite amongst her riders, and often receives commendations for her

customer service and attention to providing stop announcements for persons with visual

impairments.

Dorothy Elmore

Dorothy is a 25+year veteran of the Portland Police Bureau, including serving as an Assistant

Chief. When selecting her for the AC position, former Chief Foxworth said he chose Captain

Elmore because of her demonstrated leadership ability, commitment to community policing,

and drive to continue to look for ways to improve the Police Bureaus process for recruiting and

training the most highly qualified police officers.

Tony Mehalovich

Tony is a 26year veteran of UPS, and is currently their corporate schools facilitator, responsible

for facilitating corporate training. Prior to this role he was UPS health and safety manager for

the Oregon district, and an operations manager.


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Deb Meihoff

Deb is principal and owner of Communitas LLC, with experience in planning, development,

construction, and economic development. Deb holds a masters degree of Urban and Regional

Planning from the University of New Orleans.

Roger Pringle

Roger is the founder and leader of The Pringle Company, an executive search and consulting

firm. Roger serves on the boards of directors of four companies, and as an advisor to the board

of directors of Tillamook Cheese and to the CEO of OptionIt.

Stephanie Routh

Steph is director of the Willamette Pedestrian Coalition, a nonprofit communitybased

membership organization in the greater Portland, Oregon area dedicated to promoting walking

and making the conditions for walking safe and attractive.

Rob Sadowsky

Rob joined the BTA as executive director in June 2010. Previously, Rob served as executive

director of the Active Transportation Alliance in Chicago, Illinois for six years from 2004 to 2010.

He has over 23 years of nonprofit advocacy and management experience working on issues of

affordable housing, community economic development and transportation policy. He serves on

the board of the Alliance for Biking and Walking and the League of American Bicyclists.

Tom Walsh

Tom ispresident of Tom Walsh+Builders, Inc. and has 50 years of experience in the construction

industry. Tom also served as TriMet General Manager from 1990 to 1998.

Amy Weeden

Amy is a practice director at ACME Business Consulting. She assists clients in the design and

implementation of process change initiatives related to corporate transactions, organizational

design, change management and internal administration.


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APPENDIX B.

Safety and Service Excellence Task Force Meetings:

Summary of Issues Covered

This is a summary of the comments and discussion by topic of task force meetings held

between July 29 and October 13, 2010. It is intended to provide context to the

recommendations reached by the taskforce. There were three public meetings, one employee

meeting, four work sessions, one executive session talking with task force member Tony

Mehalovich about the UPS experience and one meeting with Pollie Sengstake, general manager

of human resources for Les Schwab. A portion of the October 6 and the entire October 13

meeting were devoted to preparing final recommendations. Those discussions are reflected in

the final report.

1. Work CultureSafety is a constant process, requiring continuous effort for continuous improvement.

A transit agency should have safety culture woven into the fabric of the agency, where

everything is viewed through a safety lens.

Safety is a mentality not a value.

In five years, TriMet should be considered in league of its own because of its safety first

attitude; safety trumps ontime performance; need to create an environment where

operators are in charge, at the top of the pyramid.

Safety should be a value, not a priority; a way of thinking about an operation; values

dont change.

Safety should be value and a priority.

There should be a zero accident culture at TriMet; the commitment to safety should be

on the first page of the Working Wage Agreement.

Safety is quality of service, systems need to be in place to improve service quality.

TriMet needs brand management; focus needs to be at the top.

Actions speak louder than words.

The general manager needs to create the culture.

The environment has changed dramatically. There is more complexity but the systems

have not changed to deal with the environmentbikes, pedestrians, traffic, etc.

Two experts who have been involved in successful workplace transformation shared their

experiences with the task force. The UPS experience, as described by task force member Tony

Mehalovich, is included throughout this summary. In addition, Pollie Sengstake, currently with


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Les Schwab, was invited to share her experiences. Both indicated that supervisors play a key

role in helping frontline employees translate and understand an organizations vision. That was

echoed by TriMet employees in their comments.

Pollie Sengstake, Les Schwab

There is too much focus on the what people do in an organization and not enough on

the how.

Organization needs to say the right things, do the right things, develop value statements

and operationalize them.

Employees do not need to be happy with change, they need to know how to be

successful with the change.

Have to be willing to let people if they are unwilling to change or they are barriers to the

new culture.

Performance management is a critical piece of ensuring vision is realized; people willdisregard what you are not measuring.

People need to find a team connection where they can be successful.

Hiring, training, awards and compensation are critical in cultural change.

The process of transformation:

o Define the what and how.o Identify formal and informal leaders.o Define the desired values, priorities and strategies.o Link values to priorities.o Hire the right people.o Align performance management system (compensation and rewards) with desired

behavior; link individual performance with company performance.

o Hold celebrations of success.o Tell the story of how externally.

2. Communication and EngagementEmployee Communication

Communication on safety must be top down and bottom up.

UPS has a Concern Log at each worksite to show hazards and managements progress

at resolving them; UPS operators report hazards to their managers for resolution.

Reroute and construction information is available in an operators pouch.

Relevant safety data should be shared with all employees and used more proactively.


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Seems to be a disconnect between what management/staff think and what operators

thinkis it just a breakdown in communication?

TriMet needs more transparency; have people like Ms. Sturdy and Mr. Sale talk with

operators.

Focus should be on bystander safety; need to give operators the tools they need tochange their attitudes; have safe drivers talk to other operators.

Find more methods (like Operators Report) to communicate with employees.

There should be more presence of transit police, management and administrative

employees in the bull pen.

Need to work on communication around hazards and incidents. What is the tolerance

level for these?

Need improved communication and more trust between drivers and management.

Lack of understanding of safety and lack of definition of safety; tolerance for lack of

safety.

Public Education/Partnerships

Only measurement tool known in transit that measures public awareness campaigns is

reductions in incidents in targeted groups; successful techniques by other transit

agencies include: blogging, public chat rooms, weekly safety outreach efforts in schools

and community user groups; other approaches can include partnering with DMV to

further educate young drivers.

TriMet has conducted a number of public outreach safety campaigns. These efforts haveincluded: integration of safety messages in existing communication tools and channels,

materials for grade, middle and high schools, outreach at venues other than schools for

kids (movie ads, skate parks, etc.), partnerships with BTA, partnerships with Operation

Life Saver. TriMet spends $40$50,000 annually on these campaigns; TriMet does not

routinely measure the impact of these campaigns, but anecdotal information suggests

recall of safety messages is high.

It was suggested that the newly formed Technology Advisory Committee might be a

good forum for municipal collaboration.

Better communication with traffic division and police.Need a public awareness campaign as well as law enforcement on the Mall.

Need to work with the public and with people who have been impacted.

Have operators make announcements when the bus is turning.

Need to build trust, reinforcement of being heard and followup on customer

involvement.


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More interaction between the operators and the people they serve.

Possibly partner with PDOT to communicate safety and communicate with partners on

sharing the road.

3. Accountability, Empowerment and SupportOrganizational Structure/Relationship

The cooperative and collaborative link between TriMets safety and training

departments appears to be culturally unique; seems like Training Department is an

extension of Safety Department at TriMet; Safety Department should be considered

consultants, not cops and should be staffed in a way to provide assistance and help.

Safety Department needs to take a more proactive role.

Concern about the structural separation of safety and training.

Not enough oversight from the top.Do a performance improvement process for safety operations.

ATU shares managements concern and commitment to safety.

Union and management need to have common ground where both are committed to

safety.

Hiring/Training

Training is an effective way to raise awareness of hazard analysis.

Emphasis has been placed on driving and customer service experience; some drawbacks

to the operators having to start as part time per the WWA; training is looking at profilesof successful operators to help in selection criteria.

Initial training for operators is six weeks, followed by six months of probation; no

recertification process for bus operators; refresher training classes are offered to

operators throughout their careers; an annual 8hour training class was suspended due

to budget limitations; trainers ride with operators once a year; videos from accidents

are used to train operators.

Need to be a people person to be a successful operator.

UPS has a higher ratio of hiring from inside than outside; UPS focuses on driver skill,

visibility, good communication and eye contact to reduce risk; UPS provides annual

recertification training.

It is important to look for best practices in the transit industry and outside of it.

Needs to be a better connection between safety and training.

Need to measure the qualities of people TriMet brings on.


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The use of parttime operators could be contradictory. The part time operators dont

know where they fit in the organization; best candidates may be screened out since only

parttime is offered.

Morale/Teamwork/Recognition/Celebration

General feeling is that employees are proud to be employed by TriMet.

Operators have a number of recognition programs, most of them have accident criteria.

Morale is low and that impacts safety.

Operators do not feel appreciated.

Need to celebrate and have fun events.

Provide greater respect to operators, they are the backbone.

Need to improve public perception of operators.

A person who is focused on safety and doing a good job, doesnt need a reward.

Create a teamwork opportunity for operators around a specific line and develop best

practices; it was suggested that the Transit Mall might be a good area to do a line

review.

TriMet needs to go beyond shelving things as each new general manager wants his/her

own changes; dont need to reinvent the wheel just fine tune it.

Change needs to be operational and someones job.

Operators need to be welltrained and healthy.

UPS philosophy is that operators need to have a healthy lifestyle and the company has

invested in a health and wellness program.

There is an opportunity in the bullpen to build advanced training, professional

development opportunities, health/wellness, higher education. Create an operator

involvement program.

Relationship between union and management is strained, need to identify the key

issues for both and find common ground.

Operators said they felt disconnected, not like a family.

Employees need to feel engaged, involved and excited about their jobs.

Employee Support/ Supervision

Encourage managers to spend more time in the field and become more available to

frontline employees.

Need to depend on supervisors and managers to ensure cultural change; people look for

confirming behavior from their managers and leaders; leadership at the supervisory

level is key.


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Need a mentoring program for operators; need to get tips and advice from senior

operators.

There should be grief and crisis counseling for operators.

Supervisors need to be supportive and have better training in communication.

If TriMet puts welltrained operators on the job, what is in place to support them? Needto put systems in place so they dont become complacent.

Safety performance is getting better, incidents are going down. Need to expect that

people will err. Need to have failsafes ready to deal with this. If a driver is overloaded, it

makes it harder to deal with stuff.

Need better support for operators during weather emergencies.

Performance Management

Operators are given a yearly summary of their performance.

For first preventable accident there is review with an operator; second there is a

retraining.

Operator pay is determined by the WWA, pay is not based on performance.

There is a formalized procedure for accident review and corrective action, operator is

subject to termination after four preventable accidents in a two year rolling period;

there is a grievance process, and it can be challenging and lengthy.

If you say you value performance, but everyone gets the s ame compensation, it doesnt

show you are a performance culture; not addressing poor performers is one of the most

destructive elements in an organization sends a powerful message to strong

performers.

Mystery shoppers are sometimes used to evaluate operators; UPS uses observation

rides, secret shoppers; customer satisfaction index to assess performance; more

emphasis is placed on anticipating problems.

4. Tools, Systems and ProcessesMeasurement/Data Analysis

Key to a safetyfirst culture is hazard identification by all employees at all levels of theorganization; must identify and address hazards; safety benchmark is not the number of

accidents, but rather the number of hazards that are identified and mitigated;

understaffed safety department makes it hard to do this analysis; transit police can play

a role in hazard analysis; suggested that TriMet collect preincident data and use near

miss data to focus mitigation efforts.


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TriMet collects a lot of data in the ACID system, but it is not always routinely queried

and analyzed to look for trends.

Station management monitors individual operator performance and tries to provide

support and coaching. If expectations are not met, progressive discipline is used.

Information is not available that shows which bus routes have the highest number ofcrashes; need to identify performance measures and use data more effectively. Need to

have three quick indicators for managers about safety.

Need more data to make specific recommendations.

Create a quarterly report of the breakdown of safety datahours of lost time, injury

crashes, etc.

Have people who operate the line work with the people who get the data, both will then

become more aware.

Safety dashboard is needed.

The general manager should be talking about the baseline, goals, and how TriMet isdoing against the goal; get the employees rallied around the goal.

TriMet should be able to pull information on the top three lines with the highest

number of incidentsuse community policing model.

Look for patterns in accidents to help identify future problems.

Need to know how many hazards there are and how many have been resolved.

Schedules and Safety

Run cuts (schedules) should take into account the hazards on each route that might

impact safety; TriMet should develop an annual recertification program for bus

operators; the security training should be reviewed and updated.

Need to create a schedule for average operator and typical day; BDS data provides an

accurate record of each schedule; scheduling staff tries to get out in field and observe

runs; room for more interaction with operators.

Conflicting views from staff and operators as to the role of ontime performance and

whether schedules are accurately written.

Concerns that operators are feeling pressured to keep schedules and that may impact

their safety; operators who are concerned about schedules cannot operator safely;

operators have a lot of control over safety and customer satisfaction, but not over

schedule and external factors.

Customer expectations for making schedule may create pressure for operators to meet

those needs.

Schedules and safety need to be looked at.

Schedules are too tight.


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Operators said schedules create a lot of pressure. Scheduling people are looking at data

but not talking to operators to see if schedules are working or if operators have any

issues with schedules.

Other

Yellow Cards: The Yellow Card process for operators to provide feedback on safety

and scheduling is viewed as a waste of time because issues dont get resolved and

information back to employees is not consistently shared; Yellow cards need reviewed;

Yellow cards need to be used proactively as a way to flag problems and improve system

operationsthey need a process flow review; Operators become the customer when

they file a yellow card and need reinforcement and trust that their issues will be acted

on and there will be followthroughyellow cards need to be resolved in a timely

manner.

SOPs: Main deficiency identified in the K&J Report was TriMets distribution of Bus

SOPs. K&J recommended TriMet establish a process for effectively distributing Bus SOPs

and provide the necessary training to ensure bus operators know and understand the

content and applicability of the SOPs.

Safety Committees: Invite Service Planning and Scheduling staff to attend Safety

Committee meetings; UPS has three minute safety meetings every day; each UPS site

has a safety committee; Safety Department should play more of a leadership role in

Safety Committees; Used to be three safety committees, one at each bus garage, now

there is one combined committee; Talent and commitment on the Safety Committee.

Closed Circuit Television Cameras (CCTV): Brief discussion after reviewing material fromother transit properties; could be some value to further review CCTV as a way to provide

additional information for training and coaching purposes.

Documents

Trimet Safety Final Report